Gynecology

List of Articles

Managing von Willebrand Disease in WomenBleeding disorders have serious implications for the practice of obstetrics and gynecology. The most common inherited bleeding disorder is von Willebrand disease (VWD), which is caused by a deficiency, dysfunction, or absence of von Willebrand factor (VWF). This disorder is caused by either a quantitative or qualitative defect in VWF. It is a common cause of heavy menstrual bleeding and other bleeding problems in women and adolescent girls. Obstetricians and gynecologists should include VWD and other bleeding disorders in the differential diagnosis when evaluating patients with heavy menstrual bleeding, regardless of age. Available treatment options for adolescents are similar to those for other women. Despite the therapeutic physiologic effect of pregnancy on patients with VWD, bleeding complications remain a significant risk to both mother and fetus. Because the risk of bleeding varies by subtype, accurate diagnosis of the disease is an essential step of care to provide recommendations regarding optimal therapy and genetic counseling. Overall, the preferred management for pregnancy that is complicated by VWD is anticipating complications by monitoring bleeding parameters. Therefore, with adequate monitoring, prophylaxis, and observation, patients with VWD can be expected to tolerate the course of pregnancy with minimal risk. Because of the importance of these guidelines for the practice of obstetrics and gynecology, the information relevant to women's health is summarized here.

Benign Vulvar Skin Disorders: Part 1Nearly one in six women will experience chronic vulvar symptoms at some point, from ongoing itching to sensations of rawness, burning, or dyspareunia. In many chronic cases, more than one entity is the cause. Specific skin diseases, sensations of rawness from various external and internal irritants, neuropathy, and psychological issues are all much more common causes of chronic vulvar symptoms than infections. Vulvar skin disorders can interfere with sexual function because of discomfort, pain, and embarrassment. Chronic vulvar conditions impact not only a womanís sexual well-being but also her overall quality of life. As women become more comfortable with vulvar health, they will seek the advice of their healthcare providers, especially about their sexual health. Gynecologist must be prepared to diagnose and treat vulvar conditions, including chronic vulvar skin disorders. A detailed history and physical examination, backed by a confident knowledge of the vulvar dermatoses, will aid in diagnosis and treatment. Focus of this review is on common benign conditions of vulvar skin: contact dermatitis; lichnoid vulvar dermatoses; extramammary Pagetís disease and squamous cell hyperplasia: their diagnosis and current management.

Menopause: Managing Mood, Memory and Female Sexual DysfunctionsThe review describes the diagnostic criteria, helpful screening tools, and initial treatment guidelines in order to better equip the obstetricians and gynecologists to manage these patients with depressive episodes, memory loss, Alzheimerís disease and female sexual dysfunctions. Sexual concerns should be addressed routinely as part of all comprehensive womenís health visits. Gynecologists are often the first health care provider a woman turns to when seeking help for sexual problems. It is important to provide a safe and non-judgmental environment that facilitates discussion of these issues. Patients and their clinicians can be reassured that for the majority of women, cognitive function is not likely to worsen in postmenopause in any pattern other than that expected with normal aging. Although it not likely that in postmenopause, a womanís cognitive function will return to what it was premenopause, she may adapt to and compensate for the symptoms with time. Stimulant medication may have a role in the treatment of subjective cognitive impairment, particularly for women with comorbid fatigue or impaired concentration who are not showing evidence of objective impairment. There is some evidence that modifying lifestyle factors can decrease the risk of dementia and even cognitive decline associated with normal aging. It is hoped that the continued research into the causes of Alzheimerís disease will provide some of the necessary information about the prevention and treatment of this relentless and socially damaging disease.

Bone Health: Osteoporosis Prevention StrategiesOsteoporosis is an important health problem affecting mature women. Americans with osteoporosis or with low bone mass, approximately 80% are women. Osteoporosis-related fractures will occur in more than 40% of women over the age of 50. Hip fractures will occur in more than 40% of women over the age of 50. An estimated 1.3 to 1.5 million fractures occurring annually are attributed to osteoporosis, accounts for about 15% of the total. Within 1 year after a hip fracture, up to 20% of the victims will die, 25% of the survivors will be confined to long-term care facilities, and 50% will experience long-term loss of mobility. Spinal fractures can be associated with pain, loss of height, and deformities. Osteoporosis also is associated with tooth loss and the resorption of alveolar ridge. Obstetricians and gynecologists play a major role in the prevention, diagnosis, and treatment of osteoporosis as outlined in this document. It is intended as an educational tool that presents current information.

Clinical Management of EndometriosisEndometriosis is a chronic and recurrent reproductive disorder with variable clinical presentations. Management varies depending on the patientís age, symptoms, extent of the disease, reproductive goals, treatment risks, side effects, and cost considerations. The purpose of this document is to review the agents used in the medical management of endometriosis and discuss the use of assisted reproduction technique (ART) for patients with endometriosis who desire pregnancy. The etiology, the relationship between the extent of disease and the degree of symptoms, the effect on fertility, and the most appropriate treatment of endometriosis remain incomplete. This review also presents the evidence, including risks and benefits, for the effectiveness of medical and surgical therapy for adult women who are symptomatic with pelvic pain or infertility or both. The latest approaches using the variety of available medical and surgical treatments are discussed as they specifically relate to the adolescent population. Endometriosis is a relatively common chronic gynecologic disorder that usually presents with chronic pelvic pain or infertility. The societal effect of this disorder is enormous both in monetary costs and in quality of life.

Vaccines & Immunizations (PDF)The Advisory Committee on Immunization Practices (ACIP) recently issued the 2011 Recommended Adult Immunization Schedule. The schedule includes a recommendation in effect as of December 21, 2010. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. Each schedule must be read with foot-notes regarding dosage and other important information, which can be found at the CDC website (link has been provided). The language in several foot-notes is changed to clarify previous wording.

Female Sexual Dysfunction Sexual intimacy is an integral part of life and is closely linked to emotional and physical well-being. Sexual dysfunction encompasses a broad spectrum of issues in the psychological, physical, interpersonal, and physiological realms. The purpose to this document is to discuss the etiology and diagnosis of female sexual dysfunction and the discussion below offers basic therapeutic approaches to the management of sexual complaints. While pharmacologic options for treating male sexual dysfunction continue to proliferate, the development of such drugs for women has lagged far behind. Now, however, a number of agents are emerging that may help to fill this gap. A discussion of the detailed evaluation and management of dyspareunia and vaginismus is beyond the scope of this article; however, diagnosis of an underlying etiology for the pain should be sought. Both disorders can benefit from education, pelvic floor physical therapy (including biofeedback and massage), and psychological counseling.

Emergency ContraceptionEmergency contraception (EC), also known as post-coital contraception and the morning-after pill, refers to the use of drugs or a device as an emergency measure to prevent pregnancy. Women, who have had recent unprotected intercourse, including those who have had a failure of another method of contraception, are potential candidates for this intervention. It is intended for occasional or back-up use, not as a primary contraceptive method for routine use. The purpose of this document is to address the progestin-only and combined oral contraceptive methods (which are the most frequently used methods and also approved by the U.S. Food and Drug Administration [FDA] specifically for emergency contraception) and briefly address the use of the copper intrauterine device (IUD) because of its use as both long-term contraception and emergency contraception. Recently approved 5-day emergency contraceptive (ulipristal acetate) by FDA is explored. Future possibilities are also reviewed. To maximize effectiveness, women should be educated about the availability of emergency contraception methods. Clinical evaluation is indicated for women who have used emergency contraceptive if menses are delayed by a week or more after the expected time or if lower abdominal pain or persistent irregular bleeding develops. Increasing emergency contraception (EC) awareness and knowledge are important priorities in the effort to prevent unwanted and unintended pregnancy.

Intrauterine ContraceptionIntrauterine device (IUD) is the second most popular contraceptive method worldwide, after sterilization. Today's women have more birth control options than ever before. And with the increased options come increased expectations. The purpose of this document is to discuss evidence regarding the safety and efficacy of the levonorgestrel intrauterine system (LNG-IUS) and copper-bearing (TCu380A) intrauterine contraception. To achieve more widespread use of IUDs among women who are appropriate candidates, health care providers should understand the risks, benefits, indications, and contraindications of IUD use. Two IUDs currently are available in the United States: 1) the copper TCu380A, and 2) the levonorgestrel intrauterine system (LNG-IUS). A growing body of evidence attests to the safety and effectiveness of IUDs and their potential role in rates of unintended pregnancy.

SterilizationWorldwide, sterilization (tubal sterilization and vasectomy) is used by more people than any other method of contraception. Female surgical sterilization is the second most commonly used method of contraception among women in the United States. The purpose of this document is to provide an overview of surgical sterilization, with a focus on tubal sterilization and the major clinical alternatives to this procedure -- vasectomy and long-acting contraceptives. The emphasis should be on the safety and effectiveness of tubal sterilization as compared with these alternatives. For women who no longer desire family, sterilization is a safe and highly effective option. With today's technology, transcervical sterilization can easily be performed both comfortably and cost-effectively in an office setting rather than operating room, making sterilization a convenient and private choice for non-reversible birth control.

Hysteroscopic SterilizationTransvaginal approaches to sterilization involve gaining access to the fallopian tubes through the cervix. A device or occlusive material is then placed hysteroscopically or blindly block each tube. The purpose of this document is to review hysteroscopic sterilization. Past, current, and upcoming techniques are reviewed to determine how they measure up to tubal ligation. Although sterilization is intended to be permanent, expressions of regret and requests for reversal are not uncommon and are much likely to occur among women sterilized at young ages. The availability and use of contraception have contributed greatly to women's health. The emphasis will be on the safety and effectiveness of hysteroscopic sterilization as compared with the alternatives.

Medical Disorders and ContraceptionDecisions regarding contraception for women with coexisting medical problems may be complicated. In some cases, medications taken for certain chronic conditions may alter the effectiveness of hormonal contraception, and pregnancy in these cases may pose substantial risks to the mother as well as her fetus. In addition, differences in content and delivery methods of hormonal contraceptives may affect patients with certain conditions differently. When selecting one of the many effective contraceptive methods available, healthcare providers and women need to consider each method's risk/benefit profile relative to the specific underlying illness. The purpose of this document is to provide information to help healthcare providers and women with coexisting medical conditions make sound decisions regarding the selection and appropriateness of various hormonal contraceptives and facilitate use of contraceptive choices that do not exacerbate medical problems. Addressed in this document are; to recognize that increased risks are associated with pregnancy in women with various medical conditions and evaluate evidence-based risks and benefits of use of intrauterine devices (IUDs) in women with various medical conditions.

Robotic Gynecologic SurgeryMinimally invasive surgical techniques for performing hysterectomies and other gynecologic surgeries have been shown to reduce patient morbidity and shorten hospital stay. The purpose of this document is to review the recent adoption, experience, and applications of robot-assisted laparoscopy in gynecologic surgery. It will likely continue to develop as more gynecologic surgeons are trained and more patients seek minimally invasive surgical options. Well-designed, prospective studies with well-defined clinical, long-term outcomes, including complications, cost, pain, return to normal activity, and quality of life, are needed to fully assess the value of this new technology. Surgical innovation is necessary. There are ethical and societal issues that remain incompletely understood about the use of robotic surgery.

Contraception: Depot Medroxyprogesterone AcetateAn unintended pregnancy represents a lost opportunity for preconceptional care for the fetus and a higher risk of pregnancy-related morbidity in the mother. Unintended pregnancies have been also associated with higher rates of unhealthy behaviors, such as smoking or alcohol use, and the lower rates of prenatal vitamin use, which increase the risk of low-birth weight infants and other adverse pregnancy outcomes. A woman's use of her contraceptive method is affected by features of the method itself (dosing frequency, ease of use, cost and availability) as well as by her perceptions about the method. The purpose of this document is to describe advantages and disadvantages of depot medroxyprogesterone acetate (DMPA) use by individual adolescent and adult women. It also evaluates evidence regarding short- and long-term effects of DMPA on skeletal health. Counseling of all reproductive-age women, about the importance of maintaining a healthy lifestyle to minimize risks of osteoporotic fractures later in life, is essential. The review utilizes an evidence-based approach to the recently approved black box changes in DMPA product labeling.

Hormonal Contraception: The Challenges AheadFor many women, safe and effective hormonal contraception is a mainstay of successful pregnancy planning and a source of important non-contraceptive benefits. Several new formulations and delivery systems for hormonal contraception offer long-term, non-daily, reversible alternatives to daily oral regimes. The availability of these new products and the continued viability of the older hormonal and non-hormonal methods allow physicians to individualize therapy according to patients' needs and preferences. The purpose of this document to summarize both technical and programmatic aspects of hormonal contraceptive use. The methods of hormonal contraception are discussed in order of efficacy from highest to lowest. We hope to help healthcare providers in clinical decision making regarding hormonal contraception use in their population and to identify and discourage the unnecessary practices, tests and procedures. Facilitating contraceptive use and reducing barriers to contraceptive provision are also discussed. The public is often aware of the risks of hormonal contraceptives that are all-too-often described by sensational reports in media; these drugs remain among the most studied products on the market, helping millions of women worldwide to safely and effectively prevent unintended or unplanned pregnancy.

Human Papillomavirus (HPV) Vaccines: A Reproductive Health PerspectiveNew vaccines designed to prevent human papillomavirus (HPV) infection have the potential to reduce the incidence of serious illness and death worldwide among women, substantially reduce emotional suffering associated with abnormal Papanicolaou (Pap) test results and the diagnosis of cervical cancer, and save significant healthcare dollars. HPV vaccines are expected to significantly reduce HPV-associated morbidity and mortality. The purpose of this article is to review some of the barriers to HPV vaccine acceptance, with a particular focus on factors relevant to female patients, parents, and healthcare providers. It also explores avenues for service delivery of HPV vaccines and critical information gap that must be bridged in order to inform future sexual and reproductive health programming. It proposes the role that the sexual reproductive health community, together with immunization and cancer control programs, could have in supporting the introduction of HPV vaccines within the context of current health systems. The benefits of HPV vaccine may not be fully realized until the vaccine is accepted by patients, parents, and healthcare practitioners. Furthermore, there may be unique issues related to the acceptance of a vaccine designed to prevent a sexually transmitted infection that is poorly understood by many women.

Adolescent Health CareAdolescent is a time of psychosocial, cognitive, and physical development as young people make the transition from childhood to adulthood. The Women's Health and Education Center (WHEC) believes healthcare professionals have an obligation to provide the best possible care to respond to the needs of their adolescent patients. The delivery of preventive services to adolescents differs from the delivery of preventive services to adults. Furthermore, not all adolescents of the same age are at the same stage of development, thus necessitating further examination of adolescent's physical, sexual, psychosocial, and cognitive development. Understanding the milestones and developmental stages of adolescence is beneficial to obstetricians and gynecologists treating adolescents. Comprehensive services may be delivered to adolescents in a variety of sites, including schools, physician offices, and community-based and other health care facilities. Legal barriers that restrict the freedom of healthcare practitioners to provide these services are also discussed.

Infertility: Evaluation & ManagementAn estimated 10% to 15% of couples who want to have a child have difficulty conceiving. At least 6.2 million couples in USA are infertile. Some experts place that number closer to 8 million. It is clear that infertility is an immense problem, not only because of the vast number of people affected, but also because of the heartache they suffer and the costs incurred by the healthcare system. The purpose of this document is to provide the understanding of evaluation of infertile couple and strategies for the management of infertility. One of the main challenges before us today is matching the right patient with the right intervention. Fertility decreases with age, especially in women; therefore the common practice of delaying childbearing for a variety of economic and social reasons has probably added to number of couples who are unable to conceive naturally. The incidence of sexually transmitted diseases that can damage reproductive structures in both men and women has risen significantly. Fortunately, we have more resources than ever for investigating the causes of infertility and then treating the condition effectively.

Sexually Transmitted DiseasesSexually transmitted diseases (STDs) represent a prevalent and compelling problem for women. As such, healthcare providers need to take a proactive approach in identifying vaginal symptoms, diagnosing infections, treating these conditions effectively, and maintaining careful follow-up with patients to help reduce the risk of recurrence or re-exposure. We hope that these materials provide valuable information and ideas that can be used to enhance the everyday care of the patients. Clinicians treating female adolescents should be prepared to offer confidential and comprehensive counseling, screening, and treatment according to established guidelines. They should also work within their communities and at the state and national levels to ensure access to medical care for all adolescents. Most importantly, clinicians can help to address this problem when caring for adolescent patients. Specifically, when providing health care for adolescents who have not yet become sexually active, abstinence from all risky behaviors should be encouraged.

Diagnosis of Vaginitis & Pelvic Inflammatory DiseaseVaginal infections represent an enormous, yet often underestimated element of female healthcare. Each year millions of women report symptoms of vaginitis to their clinician. Vaginitis can create a great deal of discomfort, stress, and anxiety in patients; furthermore these conditions may exert untoward and long-term effects on well-being, reproductivity and even mortality. The success with which vaginitis is managed depends largely on the counseling methods used by the healthcare provider. The purpose of this document is to understand three most common vaginal infections: bacterial vaginosis; candida vaginitis (yeast); and trichomonas vaginitis. Pelvic inflammatory disease (PID) and its management are also discussed to understand its causes and appropriate treatment. Vaginal infections can raise very serious concerns for patients. The manner in which women respond to the information about their infection, and how well they succeed with practices to treat it and prevent recurrences, depends largely on their healthcare provider's counseling methods.

Toxic Shock SyndromeToxic shock syndrome (TSS) was first described in children in 1978 but was quickly identified as an illness occurring primarily in menstruating women 12-24 years of age. During the 1979-1981 epidemic, tampon users were demonstrated to be 18 times more likely to develop menstrual TSS than non-users. Recent focus has shifted in conjunction with wound infections, postpartum endometritis and vaginitis; the predominance of cases continues to be related to menstruation. The purpose of this document is to understand the pathogenesis of toxic shock syndrome (TSS), clinical picture, early diagnosis and the latest advances in treatment. Of the approximately 30 million menstruating women in USA, it is estimated that 70% use tampons and over 50% of those use super-absorbent types. Almost 1,000,000 women are at theoretic risk. The incidence in menstruating women is now 6-7: 100,000 annually. The incidence on non-menstrual disease has shown only a slight increase in the past 10 years.

EndometriosisEndometriosis is the presence of tissue that resembles normal endometrium at site outside of the uterus. The anatomical areas most commonly affected by endometriosis are the ovaries, the pelvic peritoneum, the uterosacral ligaments, the fallopian tubes, the appendix and the bowel serosa. Endometriomas, or "chocolate cysts" are cysts of endometriosis within the ovary. The "gold standard" for diagnosing endometriosis is laparoscopy, with visual recognition of endometriosis lesions. The severity of endometriosis is defined by the American Society for Reproductive Medicine using a surgical staging system based on the size and location of endometriosis implants and the severity of pelvic scarring. The stages are: Stage I-minimal, Stage II-mild, Stage III-moderate and Stage IV-severe.

Uterine Myomas: A Comprehensive ReviewUterine leiomyomata are among the most frequent entities encountered in the practice of gynecology. It occurs in 20-40% of women during their reproductive years. Approximately 600,000 hysterectomies are performed per year in the United States for uterine myomas. Many surgical procedures other than hysterectomy are also commonly performed to deal with myomas. The purpose of this document is to review the literature and medical and surgical advances in the management of uterine myomas. Authors hope this helps healthcare providers the decision-making process as logical as possible.

Menopause: A Close-Up LookAs the life expectancy has increased markedly, more and more women are living longer after menopause. In western society, women can anticipate living for approximately 80 years, spending more than one third of their lives in the postmenopausal period. Menopause refers to the complete or permanent cessation of menstruation; an interval of 6 to 12 months of amenorrhea is usually necessary to establish the diagnosis of menopause. The biologic event of menopause marks a meaningful life passage for every woman. It is a transition made from the reproductive stage of life to the non-reproductive stage. This transition is the period of declining ovarian function, which usually becomes apparent clinically over the 2 to 5 years around menopause. The population of postmenopausal women continues to rise; currently approximately 470 million women in the world are of age 50 and older- a figure that is projected to increase to 1.2 billion by 2030. It is estimated that 25 million women each year pass into menopause. Several studies have shown that both the number of cigarettes smoked and the duration of smoking affects the onset of menopause and it induces earlier menopause.

Sexual Dysfunction in Postmenopausal WomenSexual dysfunction is common in postmenopausal women and the rate can be well over 80%. Pain during intercourse, decreased arousal and response, decreased frequency of sex, and loss of sexual desire are the most frequently identified problems in this population. The primary care physicians and obstetricians and gynecologists are frequently the first-line in the management of these difficulties. The purpose of this document is to enhance the understanding of sexual dysfunction in postmenopausal women and the development of a strategy for treatment or referral. Sexual problems in postmenopausal women are often amenable to fairly simple interventions that are (or can and should be) within the competence of primary care professionals. Providing postmenopausal women with reassuring reading materials and focusing on their specific concerns about sexual dysfunction will help reduce anxiety, as will physician suggestions keyed to the patient's individual need.

Alternative and Complementary Medicine for MenopauseMenopause is a journey, which lasts from 3 to 10 years on average, and each woman will experience it in her own unique way. Some women appear to pass through this time with very few physiological or emotional complaints, while others will experience mild hot flashes and some emotional ups and downs.† This change brings about a myriad of important health risks, many of which can be eliminated or reduced with hormone replacement therapy (HRT). Despite the benefits of HRT some women are not candidates for this treatment and many others choose not to take it. For our purposes today, the context is unconventional therapies that fall under the umbrella of what is being called "Alternative and Complementary Medicine". It comprises a very wide range of therapies, including botanical and behavioral, and other practices such as acupuncture and biofeedback. "Alternative" implies "instead of" conventional treatment, whereas "complementary" refers to something used in addition to conventional treatment. Acupuncture is licensed in about 30 states but not in others, and covered by some insurance companies. Biofeedback falls within conventional therapy for migraine but is still considered unconventional therapy for cancer. The term "integrative medicine" helps to get away from the thinking of "us versus them". The idea is to draw on the best of what exists from around the world. To achieve better medical treatment, we may "integrate" current mainstream medical practices with other approaches. The main thing is to be open to what works best for the patients.

Contraception and New MillenniumThe new millennium has brought optimism to the field of family planning. Recent research and modification to existing contraceptive products have generated confidence, among both healthcare professionals and the public, in the safety, efficacy, and importance of contraceptives. According to World Health Organizationís (WHO's) statistics there are an estimated 200 million pregnancies around the world each year, and one third of these, or 75 million, are unwanted. These pregnancies contribute to women's health problems in two ways. First, unwanted pregnancy can threaten women's health or well being because she may have existing health problems or lack of support and resources, which she needs to have a healthy pregnancy and raise a healthy child.

Dysfunctional Uterine BleedingDysfunctional uterine bleeding (DUB) is abnormal bleeding from the uterine endometrium that is unrelated to an anatomic lesion of the uterus. The purpose of this document is to provide management guidelines for the treatment of patients with menstrual irregularities associated with anovulation based on the best available evidence. Dysfunctional uterine bleeding anovulatory type is the most common form of non-cyclic uterine bleeding and it is a condition for which women frequently seek gynecologic care and accounts for considerable patient anxiety and inconvenience. The choice of treatment for anovulatory bleeding depends on several factors, including the woman's age, the severity of her bleeding, and her desire for fertility. Over the last decade, significant advances have been made in the evaluation and management of women with anovulatory bleeding.

Premenstrual DisordersPremenstrual physical and mood symptoms are common among reproductive-age women, but diagnostic criteria and treatment strategies to recognize premenstrual disorders are not always clearly understood. The purpose of this document to examine the evidence for commonly used approaches in the treatment of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). Until recently, the difficulty in managing PMS / PMDD was largely attributed to imprecise diagnostic criteria, poorly designed clinical trials, and promotion of treatment options for which there was no scientific support. In the mid-1980s, however, rigorous criteria for the diagnosis of PMS / PMDD were defined. Since then, most studies of pathophysiology and treatment have met recognized standards of scientific design. Selective serotonin reuptake inhibitors (SSRIs) are found to be effective in treating PMS / PMDD symptoms and many other treatment options are discussed.

VulvodyniaVulvovaginal disorders are increasingly recognized as a source of significant pain and discomfort and lead to a substantial decrease in quality of life for many women. The purpose of this document is to discuss signs, symptoms and management of vulvodynia. Provoked vestibulodynia, formerly referred to as vulvar vestibulitis syndrome, is suspected to be the most frequent type of vulvodynia in premenopausal women. In addition to disrupting sexual functioning, there is preliminary evidence to suggest that this pain problem can adversely affect general psychological well-being and overall quality of life. Despite its high prevalence and associated negative sequelae, there is a dearth of controlled treatment outcome studies focusing on vulvodynia. Although there are now several published studies evaluating different treatment approaches for vestibulodynia, there are only a handful of randomized trials, resulting in a hodgepodge of interventions for which there is little empirical support. Thus, current guidelines and recommendations are largely based on clinical observations and uncontrolled data rather than being anchored in findings from rigorous studies.

Obesity In The United StatesObesity has in fact become so prevalent that the World Health Organization (WHO) has classified it as a global epidemic. The past two decades in particular have seen an explosion of the rates of obesity, especially in the United States. The economic, social and psychological burden of obesity on the individual and on society will continue to grow until the factors contributing to the increasing rates of obesity over the past two decades are identified and addressed. Though this article has focused on how an individual can approach obesity, society needs to develop a plan of action. Encouraging physical activity programs in schools and communities for children, developing cheap, healthful alternatives to fast food, providing better social and psychological support to those struggling with chaotic lifestyles, and redefining work load and the workplace so they are more compatible with maintaining healthy, balanced personal lives may be some strategies to consider.

Polycystic Ovary SyndromePolycystic ovary syndrome (PCOS) is a condition of unexplained chronic anovulation state. The purpose of this document is to enhance understanding of the best available evidence on the diagnosis and clinical management of polycystic ovary syndrome (PCOS). A question which has puzzled gynecologists and endocrinologists for many years is what causes polycystic ovaries. The characteristic polycystic ovary emerges when a state of anovulation persists for any length of time. Whether diagnosis is by ultrasound or by the traditional clinical and biochemical criteria, a cross-section of anovulatory women at any one point of time will reveal that approximately 75% will have polycystic ovaries. Variety of treatments of PCOS is also discussed in this chapter and the healthcare providers must appreciate the clinical impact of anovulation and should undertake appropriate managements.

Ovulation Induction Strategies for Infertility ManagementApproximately 20% of infertile women have ovulatory disorders. When anovulation is the only infertility factor, the prognosis for pregnancy is very good because modern ovulation induction strategies are highly effective. When anovulation can be attributed to a specific treatable cause, ovulation induction can achieve pregnancy rates comparable to those observed in the normal population. The purpose of this document is to understand various modalities of ovulation induction. Anovulation is among the most common causes of infertility, and clinicians caring for infertile couples must have a thorough understanding of the many treatment options, their indications, and their risks. With these goals in mind, this article reviews the principles that guide both the traditional therapies and more recently described treatment strategies.

Understanding Assisted Reproductive TechnologyOver the past two decades, the use of assisted reproductive technology (ART) has increased dramatically worldwide and has made pregnancy possible for many infertile couples. ART encompasses all techniques involving direct manipulation of oocytes outside of the body. The purpose of this document is to provide an understanding, overview and indications for assisted reproductive technologies (ART). The results and complications of ART with an emphasis on newly developing technologies and areas of controversy are also discussed. Pregnancy rates after ART have shown nearly continuous improvement in the years since its conception. A number of factors affect the pregnancy rate, with the most important being a woman's age. Many studies are now finding that there is a slight increase in adverse pregnancy outcomes after ART. Although the vast majority of children born from these procedures are healthy, there is some concern about increased rates of prematurity, small for gestational age infants and a slight increase in the rates of birth defects following ART. Some of these complications can be linked to the problem of multiple gestations which are common following ART.

Contraception Counseling & ComplianceContraception is a women's health issue. It is about choices and human rights, not fear, guilt and shame. The negative images and concepts perceived regarding family planning and contraception in some religious and social arenas are the major factors for non-compliance and meager usage of birth control methods in many areas of the world. The purpose of this document is to help healthcare providers and women to identify their individual health care needs, and to make choices that will meet those needs. It also means that the patient has satisfied her personal preferences and arrived at the choice that best fits her life. A fundamental tenet in ethical, female-centered care is that women have a right to participate in their choice of contraceptive method. A woman who has actively chosen a method is more likely to use it consistently and correctly. Health benefits of hormonal contraception are also discussed. All contraception-methods offer health benefits in terms of reduced risk of unintended pregnancy, abortion, ectopic pregnancy, pregnancy complications, and pregnancy-related death. The help comes in focusing attention on the section of society with the most desperate needs.